NURS 225 PSU Final Review (GI Disorders, Hepato-Biliary)

4.1 UPPER GI DISORDERS

Gastroesophageal Reflux Disease (GERD)

Backward flow of acidic stomach contents in esophagus

GERD Etiology

- Inappropriate relaxation of the lower esophageal sphincter

- Can be worsened by a hiatal hernia

GERD Clinical Manifestations

- Heartburn

- Reflux

- Chest pain

GERD Diagnosis

- Clinical history

- Acid Suppression Trial

- Endoscopy

GERD Complications

- Esophageal strictures

- Barrett's Esophagus

- Bronchospasm

- Aspiration

Barrett's Esophagus

- Squamous to columnar epithelium

- Precancerous

GERD Treatment

Meds

- Proton Pump Inhibitors (PPIs)

- H2 Blockers

- Antacids PRN

- Elevate HOB

- Lifestyle changes

Factors that exacerbate GERD

- Recumbent Position (laying down)

- Large meals

- Alc

- Caffeine

- Nicotine

- Mint

- Carbonated Bev

Esophageal Cancer

Squamous Cell Carcinoma & Adenocarcinoma

Squamous Cell Carcinoma Risk Factors

Smoking & Alc

Adenocarcinoma Risk Factors

Barrett's Esophagus

Esophageal Cancer Clinical Manifestations

- Progressive

- Dysphagia

- Odynophagia

- Regurgitation

- Weight loss

Esophageal Cancer Diagnosis

Esophagogastroduodenoscopy (EGD) w/ biopsy

Esophageal Cancer Treatment

- Pre-op radiation & Chemo

- Surgical Resection

- Palliation (Esophageal dilation & stenting)

Gastritis and Peptic Ulcer Disease (PUD)

Imbalance between aggressive and protective factors

Aggressive Factors

- Acid and Pepsin

- Helicobacter Pylori (H Pylori)

- Alc

- Drugs (Aspirin/NSAIDS) --> Suppresses Prostaglandin synthesis

Protective Factors

- Mucosal Barrier

- Bicarbonate Secretion

- Tight Fitting Epithelial cell surface

H Pylori

- Gram neg rod

- Colonizes mucus secreting cells of stomach

- Secretes enzymes that interfere w/ protection of gastric mucosa

- Produces an inflammatory response

H Pylori Diagnosis

- Blood test for H Pylori antibodies

- Stool test for H Pylori antigens

- Biopsy on endoscopy

H Pylori Treatment

- 2 or more antibiotics

- Plus a PPI

Gastritis

Partial erosion of gastric mucosa

Gastritis Symptoms

- Pain

- N/V

- Upper GI bleed

Gastritis Diagnosis

Endoscopy

H Pylori testing

H+H

Gastritis Treatment

- Treat H Pylori

- PPI

- Eliminate causative factors

Peptic Ulcer Disease (PUD)

Complete erosion of GI mucosa

- Gastric Ulcer

- Duodenal Ulcer

- Stress Ulcer

Gastric Ulcers

- Pain after meals

- Highly assoc. w/ NSAIDS or ASA

Duodenal Ulcers

- Pain between meals (at night)

- Relieved w/ food/antacids

Stress Ulcers

- Transient ischemia assoc. w/ hypotension, burns, trauma, etc.

PUD Risk Factors

H Pylori

NSAIDS, ASA, Corticosteroids

ETOH (alc)

Tobacco

Zollinger-Ellison Syndrome

NOT FOOD ASSOC.

PUD Complications

- GI bleed

- Perforation

- Gastric outlet obstruction

PUD Diagnostics

- Endoscopy

- Biopsy

- H Pylori testing, CBC, CMP

PUD Treatment

- PPI

- Sucralfate (Carafate)

- H Pylori Therapy

- Lifestyle mods

- Surgery (rare)

Upper GI Bleed Symptoms

- Coffee grounds emesis

- Melena: Black, tarry stool

- Pallor

- Dizziness/Weakness

- Can be painless

Upper GI Bleed History

- Prior PUD

- ASA or NSAIDs Use

- Anticoagulants

Upper GI Bleed Management

- Hemodynamic stabilization

- V/S

- Labs: CBC, CMP, ABGs, PT/INR, aPTT

- Fluid Replacement

- Transfusions

- Supplemental O2

- Prep for Endoscopy

- PPI

Perforation

Spillage of GI contents into peritoneum

- Sudden severe pain radiating to shoulder

- Board-like ab

- Absence of bowel sounds

- Bacterial peritonitis / Surgical Emergency

-Notify provider

Gastric Outlet Obstruction

Inflammation/Edema of pylorus

- NG Tube

- Replace fluids/lytes

- Surgery if fails to resolve

4.2 LOWER GI DISORDERS

Irritable Bowel Syndrome (IBS) Patho

Disordered motility

Visceral Hyperalgesia

IBS Clinical Manifestations

- Altered bowel habits

- Ab Pain (Often relieved by defecation)

- Bloating/Distention

IBS Absent Manifestations

- Bleeding

- Night Symptoms

- Fever

- Weight Loss

IBS Clinical Management

- Fiber supplements

- Avoid offending foods

- Limit caffeine and alc

- Limit meds

IBS Etiology

Not completely understood

- Theories focus on: Neuro-hormonal mechanisms & Bacterial overgrowth

Inflammatory Bowel Disease (IBD)

Immune Modulated inflammatory disorders of the GI tract

- Ulcerative Colitis (UC)

- Crohn's Disease

IBD Patho

- Failure of immune regulation

- Genetic predisposition

- Environmental triggers

- Smoking

Smoking

Increases risk of Crohn's Disease

Decreases risk of Ulcerative Colitis (UC)

Ulcerative Colitis (UC)

Limited to colon and rectum

- Usually begins distally

- Effects mucosal layers

- Onset in adolescents or young adults

- Results in bloody diarrhea and ab pain (10-20 bloody stools a day if severe)

- Formation of abscesses

- Continuous lesions

- Characterized by exacerbations and remissions

UC Complications

- Weight loss

- Fluid/lyte imbalances

- Anemia

- Perforation

- High risk of Colon CA

- Toxic Megacolon

- Extra-Intestinal

Toxic Megacolon

Large inflammation in the colon

- Inability to contract

UC Extra-Intestinal Complications

Erythema Nodosum

Uveitis

Ankylosing Spondylitis

Erythema Nodosum

Subcut skin inflammation

Uveitis

Eye inflammation

Ankylosing Spondylitis

Spine inflammation

UC Diagnosis

- History and exam

- Sigmoidoscopy/Colonoscopy w/ biopsy

(Avoid in acute exacerbation)

- Stool studies

UC Treatment

- NPO or Low Residue Diet for exacerbation (easy on the colon)

- Mesalamine (Asacol)

- Corticosteroids

- IV Fluids

- TPN --- IV nutrition

- Iron Supplements

- TNF-Inhibitors

TNF-Inhibitors

- Infliximab (Remicade)

- High risk of infection

- Must be tested for TB before therapy

Low Residue Diet

Low Fiber

Low Fat

NO Dairy

Colectomy Surgical Options

Ileostomy

Koch Pouch

Ileal Pouch Anal Anastomosis: Requires that part of rectum can be preserved

Crohn's Disease

Occurs anywhere in GI tract

- Transmural

- Skip lesions

- Most Affected: Terminal Ileum

Crohn's Disease Clinical Presentation

- Diarrhea

- Fever

- Fatigue

- Weight loss

- Ab pain

- Anemia

- Malnutrition

- Deficiency of fat soluble vits

Crohn's Disease Complications

- Fistulas

- Strictures/Obstruction

- Perforation

- Abscesses

- B-12 Deficiency

Crohn's Disease Diagnosis

- Stool studies

- Upper GI studies w/ small bowel follow-through

- Capsule Endoscopy

- Colonoscopy

Crohn's Disease Treatment

- Low Residue Diet

- Elemental feeding

- IV Fluids

- TPN

- Corticosteroids

- TNF-Inhibitors

- B-12 Injections

- Surgery (not curative & risk of short bowel)

Infectious Enterocolitis

Viral Infections

Bacterial Infections

Parasitic Infections

Infectious Enterocolitis: Viral

Virus destroys epithelial cells and disrupt absorptive function

- Norovirus

- Rotovirus: VACCINE AVAILABLE

- Illness is self-limited

Infectious Enterocolitis: Viral Treatment

Support & Hydration

Infectious Enterocolitis: Bacterial

Results from bacterial toxins or bacterial destruction of intestinal mucosa

- More severe

- Bacteria: Staphylococcus Aureus, Salmonella, Shigella, Campylobacter, E. Coli

- Treatment --> Antibiotics

Infectious Enterocolitis: Parasitic

Protozoal infection

- Contaminated water

Clostridium Difficile (C-Diff)

Spore-forming bacteria

- Resistant to hand gel and most surface cleaners

- Proliferates when normal intestinal flora is altered

- Secretes a toxin that causes a colitis and diarrhea

- Severe cases cause: Pseudomembranous Colitis

C. Diff Diagnosis

Stool for C-diff toxin

C. Diff Treatment

- Metronidazole or PO Vancomycin

- Probiotics

Intestinal Obstruction Mechanical Etiology

Small Bowel

Large Bowel

Intestinal Obstruction Mechanical: Small Bowel

- Adhesions (MOST COMMON)

- Hernias

- Malignancy

- Intussusception

Intussusception

Bowel folds in on itself

Intestinal Obstruction Mechanical: Large Bowel

- Cancer (MOST COMMON for COLON)

- Volvulus

- Diverticular Disease

Intestinal Obstruction Mechanical Diagnostic Tests

X-Ray or CT

- Air/fluid lvls

- Free air under the diaphragm --> Indicates perforation

Intestinal Obstruction Mechanical Treatment

- Replace fluids/lytes

- Pain management

- Decompress w/ NG Tube

- Surgical correction

Intestinal Obstruction Mechanical Nursing Care

- Assess & treat pain/vomiting

- Assess fluid/lytes

- IV site/fluid admin

- NGT care

- Prep for surgery if indicated

Small Bowel Obstruction

Fluid/lyte sequestrated in bowel

- Decreased Intravascular Vol.

- Wave like pain

- Vomiting

- High pitched bowel sounds above obstruction

Paralytic Ileus

Loss of peristalsis

Paralytic Ileus Etiology

- Surgery

- Drugs (Narcotics, Opioids)

- Neurological Disease

Diverticular Diseases

Diverticulosis

Diverticulitis

Diverticulitis

Pockets become obstructed

- Results in infection w/ micro-perforation

- May result in abscess, perforation, peritonitis

Diverticulosis

Outpouching in colon wall

- Results from chronic constipation and high intraluminal pressure

- Usually sigmoid

Diverticulitis Clinical Presentations

LLQ Pain

Fever

Nausea

Diarrhea

Rectal Bleeding

Diverticulitis Acute Care

- NPO or clear liquids

- Antibiotics

- IV fluids if NPO

- Surgery if perforation

Diverticulitis Recovery

- Advance diet

- Increase fluids and fiber

- Avoid nuts, seeds, popcorn

Appendicitis

Appendix becomes obstructed w/ a fecalith

- Appendix becomes inflamed, infects, and possibly gangrenous

Fecalith

Hard piece of lodged stool

Appendicitis Clinical Manifestations

- Vague ab pain then localizes to RLQ, N/V

- Fever, increased WBC count, Rebound Tenderness

Appendicitis Diagnosis

- History and exam

- Increased WBC count

- Ab CT

Appendicitis Treatment

- NPO

- IV Fluids

- Antibiotics

- Surgery

Peritonitis

Inflammation and infection of the peritoneal lining

Peritonitis Etiology

- PID

- Appy w/ rupture

- Trauma

- Diverticulitis w/ rupture

- Perforation

- Peritoneal Dialysis

- Ascites w/ spontaneous bacterial peritonitis (SBP)

- Post-Op bowel resection

Peritonitis Clinical Presentation

- Fever

- Increased WBC Count

- Ab Pain

- Rigid, board-like ab

- Guarding, rebound

- Absent Bowel Sounds

- Sepsis

Peritonitis Treatment

- NPO

- IV Fluids

- IV Antibiotics

- Prep for surgery

Colon Polyps

- Adenomas (Pre-cancerous)

- Diagnosed and removed by Colonoscopy

- Need for repeat Colonoscopy Q 2-3 yrs

Colon Cancer

- Highly treatable in early stages

- As disease progresses it spreads through the bowel wall to lymph nodes then to liver.

Colon Cancer Risk Factors

Age > 50

Family History

IBD

Familial Polyposis